Provider Demographics
NPI:1073506713
Name:TAN, EDWIN C (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:C
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WALKER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4135
Mailing Address - Country:US
Mailing Address - Phone:212-226-8866
Mailing Address - Fax:212-226-2289
Practice Address - Street 1:13626 37TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6533
Practice Address - Country:US
Practice Address - Phone:718-886-1200
Practice Address - Fax:718-886-3901
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132804208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00377633Medicaid